Anatomic or reverse total shoulder for primary glenohumeral osteoarthritis? What do 10 recent articles say?

There is a growing trend to treat primary glenohumeral osteoarthritis in older individuals with reverse total shoulder arthroplasty (RSA). However, as pointed out by the authors of Limited Preoperative Forward Flexion does not Impact Outcomes Between Anatomic or Reverse Shoulder Arthroplasty for Primary Glenohumeral Arthritis (Sears 2024), "RSA has been shown to generally result in diminished range of motion, particularly internal rotation, compared to anatomic TSA. Additionally, RSA has several unique complications not seen in TSA patients including dislocation, component dissociation, scapular spine fractures and scapular notching."

These authors compared the minimum two year outcomes between TSA and RSA in matched patients under the age of 80 years with primary glenohumeral arthritis and limited preoperative active forward flexion (≤90 degrees). The average preoperative active forward flexion was 68±20 for the TSA and 64±19 for the RSA  groups. The post operative ranges of active flexion were 141±22 and 139±21.

They also examined a subset of matched patients having TSA and RSA with severely limited preoperative forward flexion (≤70 degrees). They found no significant differences in postoperative forward flexion, external rotation, strength, ASES score, VAS, Constant score, SANE score or revision rates between the the TSA and RSA groups. The limited active forward flexion TSA group achieved significantly improved internal rotation compared to the RSA group. 

This article prompted a review of some of the other articles published in 2023 and 2024 that compared TSA and RSA. Eight of these articles addressed particular subsets of patients with glenohumeral arthritis/intact cuff: limited active flexion, limited external rotation range, weak external rotation, and age. The chart below allows the reader to compare the pre and final post operative range of active forward flexion for the shoulders in these eight articles. 

Here is a brief review of the articles.

Comparison between Anatomic Total Shoulder Arthroplasty and Reverse Shoulder Arthroplasty for Older Adults with Osteoarthritis without Rotator Cuff Tears (Kim 2024) compared the clinical outcomes of anatomic TSA and reverse shoulder arthroplasty (RSA) in patients aged over 70 years with primary glenohumeral osteoarthritis without rotator cuff tears. Of the 67 patients included in this study, TSA was performed in 41 patients, and RSA was performed in 26 patients. The two groups had no clinical differences in the patients’ preoperative demographic and radiographic data. At final follow-up, both groups showed improved pain, ROM, and functional outcomes. The TSA group demonstrated significantly better postoperative ASES and Constant-Murley scores than the RSA group. The TSA group showed significantly better postoperative active forward flexion, external rotation and internal rotations than the RSA group. 

In Reverse shoulder arthroplasty with preservation of the rotator cuff for primary glenohumeral osteoarthritis has similar outcomes to anatomic total shoulder arthroplasty and reverse shoulder arthroplasty for cuff arthropathy (Nazzal 2023) TSA was compared to RSA in shoulders with preservation of the rotator cuff. While the TSA patients had more external and internal rotation, there were no significant differences in outcome scores or complication rates.

Patients 75 years or older with primary glenohumeral arthritis and an intact rotator cuff show similar clinical improvement after reverse or anatomic total shoulder arthroplasty (Ardebol 2023) studied patients 75 years of age or older who underwent TSA (n=67) or RSA (n=37) for primary GHOA with an intact rotator cuff with a minimum 2-year follow-up.  The TSA cohort showed significantly greater improvement in external rotation; however both TSA and RSA provided similar clinical outcomes otherwise. 

Clinical outcomes of anatomic vs. reverse total shoulder arthroplasty in primary osteoarthritis with preoperative rotational stiffness and an intact rotator cuff: a case control study (Hao 2023) compared stiff patients(ER ≤ 0 degrees) having RSAs to matched stiff patients having TSAs.  Postoperative outcome scores were similar across all matched cohort comparisons. Preoperative limitations in passive ER did not appear to be a limitation to utilizing TSA.

Clinical outcomes of anatomical versus reverse total shoulder arthroplasty in patients with primary osteoarthritis, an intact rotator cuff, and limited forward elevation (Trammel 2023) compared the minimum 2 year outcomes in matched patients with glenohumeral osteoarthritis, an intact rotator cuff, and limited forward elevation (FE ≤ 105°) having TSA (n=344) or RSA (n=163). The outcome scores were significantly better in stiff RSAs compared with stiff TSAs. The complication rate did not significantly differ between stiff TSAs and stiff RSAs, but there was a significantly higher rate of revision surgery in stiff TSAs.

After accounting for confounders, the authors of Similar rates of revision surgery following primary anatomic compared with reverse shoulder arthroplasty in patients aged 70 years or older with glenohumeral osteoarthritis: a cohort study of 3791 patients (Orvets 2023) observed no significant difference in all-cause revision risk for RSA vs. TSA . The most common reason for revision following RTSA was glenoid component loosening. Over half of revisions following TSA were for rotator cuff tear. No difference based on procedure type was observed in the likelihood of 90-day ED visits or 90-day readmissions.

Clinical outcomes of anatomic vs. reverse total shoulder arthroplasty in primary osteoarthritis with preoperative external rotation weakness and an intact rotator cuff: a case-control study (Hones 2024) analyzed the two year minimum outcomes for 333 TSAs and 155 RSAs performed for primary cuff-intact osteoarthritis and having ER weakness (strength <3.3 kilograms (7.2 pounds)). When comparing weak TSA vs.weak RSA, no differences were found in postoperative outcome measures, rate of complications or rate of revision surgery. 

Reverse total shoulder arthroplasty for primary osteoarthritis with restricted preoperative forward elevation demonstrates similar outcomes but faster range of motion recovery compared to anatomic total shoulder arthroplasty (Karimi 2024) sought to determine whether there was a difference in functional outcomes and postoperative range of motion between TSA and RSA in patients with preoperative restricted motion (≤90 degrees of active elevation). There was no difference in outcome scores between RSA (57 patients) and TSA (59 patients). Postoperative active ROM was similar between RSA and TSA cohorts in forward flexion and external rotation. However, internal rotation was less in the RSA group. There was no statistically significant difference in complication rates between cohorts. 

Reverse total shoulder replacement versus anatomical total shoulder replacement for osteoarthritis: population based cohort study using data from the National Joint Registry and Hospital Episode Statistics for England (Valsamis 2024) sought to compare the risk-benefit and costs associated with reverse total shoulder replacement (RSA) and anatomical total shoulder replacement (TSR) in patients having elective primary shoulder replacement for osteoarthritis. RSA had a reduced hazard ratio of revision in the first three years with no clinically important difference in revision-free restricted mean survival time, and a reduced relative risk of reoperations at 12 months. Serious adverse events and prolonged hospital stay risks, change in Oxford Shoulder Score, and modelled mean lifetime costs were similar. Outcomes remained consistent after weighting.  Despite a significant difference in the risk profiles of revision surgery over time, no statistically significant and clinically important differences between RSA and TSA were found in terms of long term revision surgery, serious adverse events, reoperations, prolonged hospital stay, or lifetime healthcare costs.

Comment: These articles show similar outcomes for anatomic and reverse total shoulder arthroplasty in treating patients with primary osteoarthritis with an intact rotator cuff, even for older patients, stiff shoulders and weak shoulders. 

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).